Factors influencing return-to-work following upper extremity surgery

Abstract

The upper extremities are necessary to independently perform everyday activities, engage with the environment and others and, importantly, work. Unfortunately, upper extremity (UE) conditions, resulting in pain and impairments, are common. Although returning to work is usually straightforward, for some it can be difficult and prolonged, impacting significantly on the worker, key stakeholders and society. This thesis utilized mixed methodology to explore factors influencing RTW following surgery for traumatic and non-traumatic UE conditions. Specifically, the overall aims were to: 1) identify gaps in the literature; 2) generate a list of factors influencing RTW; 3) explore stakeholders perspectives of barriers and the strategies to facilitate RTW; 4) determine the assessment tools used by health care providers (HCPs) to evaluate RTW barriers; 5) clarify a definition for delayed RTW; and 6) explore injured workers’ lived experiences to understand the context surrounding the factors and processes that may influence RTW. A scoping review identified gaps in the literature (Aim 1), generating the remaining thesis aims. A systematic review of prognostic studies for RTW following a common UE surgery, carpal tunnel release, was then conducted (Aim 2). This review revealed an inconsistent and low level of evidence for any studied prognostic factor for RTW or work disability. A three-round Delphi study determined expert opinion on the barriers and facilitators for RTW following surgery for non-traumatic UE conditions (Aim 2). Thirty-one experts completed all rounds. Strong consensus was achieved for these barriers: mood disorder; symptoms at more than one site; heavy UE work exertions; lack of flexible RTW arrangements; lack of supervisor support; and high pain catastrophising. Strong consensus was achieved for these facilitators: high motivation to RTW; high RTW and recovery self-efficacy; availability of modified duties; flexible RTW arrangements; positive coping skills; limited heavy UE work exertions; no catastrophic thinking; no fear avoidance to RTW, pain or activity; return to meaningful work duties; supportive RTW policies; supportive supervisor; and high job satisfaction. A cross-sectional study of 1011 RTW stakeholders (HCPs, employers, insurers and lawyers) was conducted. This study contained four sub-studies. In the first sub-study, a list of factors that stakeholders perceived influence RTW was generated (Aim 2). Highest agreement was found for: RTW self-efficacy; post-operative psychological status; supportive employer or supervisor; employer’s willingness to accommodate job modifications; worker’s recovery expectations; mood disorder diagnosis; post-operative pain level; and whether the job can be modified. Disagreements between stakeholder groups existed for a third of the factors. Further analysis of the 787 HCPs was conducted in sub-study two (Aim 2). This revealed that HCPs rated difficulty coping with the pain as the main RTW barrier. Few differences between the disciplines existed. In sub-study three, 621 of the stakeholders reviewed a hypothetical complex case to identify RTW barriers and strategies (Aim 3). Stakeholders identified similar RTW barriers but different strategies. More psychological and social barriers, than biological or demographic barriers, were identified. Employers and insurers identified similar strategies. However, the HCPs nominated more biological strategies. In sub-study four, the HCPs nominated 59 types of assessment tools/methods that they use to identify RTW barriers for workers with UE conditions in clinical practice (Aim 4). The most favoured method was clinical interviewing. Other commonly used tools were strength measurement, and the Orebro Musculoskeletal Screening Questionnaire. A definition for ‘delayed RTW’ was clarified by consulting 42 international experts (Aim 5). Experts were divided between definitions. Furthermore, two thirds of experts believed universal time-based cut-offs should not be used to delineate transition from an early to delayed RTW. To understand workers’ RTW experiences, a qualitative study was undertaken. Interviews with 34 workers generated two sub-studies (Aim 6). The first sub-study revealed that workers’ experiences of encounters with insurers, employers and HCPs were embedded within the structural context of the workers’ compensation system. These encounters were influenced by: stakeholders’ responses to conflicting organizational mandates; stakeholders’ responses to a system designed to ‘fit’ the average worker; and, the workers’ limited decision-making regarding treatments and RTW options. The second sub-study described the theme of ‘loss’ experienced by the workers and how loss influences the RTW process. The primary loss occurred when workers sustained the UE injury. Secondary, often snowballing, losses precipitated (e.g., related to work, relationships, self). Losses were intensified by workers’ compensation systems problems influencing how workers responded to their losses. Issues related to loss of control and trust were intensified by systems problems which impacted on work-related outcomes. This thesis’ findings contribute to understanding the factors influencing RTW for workers with UE conditions, from the workers’, employers’, HCPs’, insurers’, lawyers’ and international experts’ perspectives. Recommendations for a longitudinal study of prognostic factors for RTW (and long-term work disability) for workers with UE conditions are documented. Future research should also aim to understand the influence of workers’ compensation systems, and the complexities of stakeholder interactions to improve work disability outcomes.